Nokea
When caring for a client with a spinal cord injury, the nurse continually monitors this client for which medical emergency?
- A. Hemorrhage
- B. Hypovolemic shock
- C. Gastrointestinal atony
- D. Autonomic hyperreflexia
Correct Answer: D
Rationale: Autonomic hyperreflexia (D) is a medical emergency in spinal cord injury (SCI) above T6, causing severe hypertension from unopposed sympathetic response. Hemorrhage (A) or shock (B) requires trauma context. GI atony (C) is chronic, not emergent. D is correct. Rationale: Hyperreflexia, triggered by stimuli like bladder distension, can lead to stroke or death if untreated, requiring urgent monitoring and intervention, per SCI emergency protocols, unlike less acute complications.
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Which of the following is the nurse's role in the health promotion
- A. Health risk appraisal
- B. Teach client to be effective health consumer
- C. Worksite wellness
- D. None of the above
Correct Answer: B
Rationale: Teaching clients to manage their health effectively is a key nursing role in promotion.
Caring is healing, it is communicated through the consciousness of the nurse to the individual being cared for. It allows access to higher human spirit.
- A. Benner
- B. Watson
- C. Leininger
- D. Swanson
Correct Answer: B
Rationale: Jean Watson's Human Caring Theory, developed in the 1970s, defines caring as a healing force transmitted through the nurse's consciousness, connecting to the patient's spirit. She sees nursing as transcending physical acts, fostering openness to a higher human essence. Unlike Benner's skill progression, Leininger's cultural focus, or Swanson's process model, Watson's approach is deeply philosophical, emphasizing transpersonal caring moments like a nurse's empathy soothing a dying patient's fear. Her 10 Carative Factors (e.g., instilling hope) guide this spiritual exchange, influencing holistic nursing practices globally, particularly in palliative care, where emotional and existential support is paramount.
A client reports difficulty sleeping at night, which interferes with daily functioning. Which intervention should the nurse suggest to this client?
- A. Avoid beverages containing caffeine
- B. Take a sleep medication regularly at bedtime
- C. Watch television for 30 minutes in bed to relax before falling asleep
- D. Advise the client to take several naps during the day
Correct Answer: A
Rationale: The correct answer is A: Avoid beverages containing caffeine. Caffeine is a stimulant that can interfere with sleep, making it difficult for the client to fall asleep at night. Taking sleep medication regularly (choice B) may not address the root cause of the sleep difficulty and can lead to dependency. Watching television in bed (choice C) can actually stimulate the brain and hinder relaxation before sleep. Advising the client to take several naps during the day (choice D) can disrupt the sleep-wake cycle further. Therefore, recommending the avoidance of caffeine-containing beverages is the most appropriate intervention to help the client improve their ability to sleep at night and function better during the day.
The nurse treated Mr. Gary's pain before other tasks. This is an example of?
- A. Priority setting
- B. Decision-making
- C. Health literacy
- D. Care coordination
Correct Answer: A
Rationale: Treating pain first is priority setting (A) need-based order, per definition. Decision-making (B) chooses, literacy (C) understanding, coordination (D) organization not priority-specific. A fits the nurse's focus on Mr. Gary's urgency, making it correct.
When administering an IM injection to a 5-month-old infant, which of the following injection sites should be used?
- A. Deltoid
- B. Ventrogluteal
- C. Vastus lateralis
- D. Dorsogluteal
Correct Answer: C
Rationale: For infants and young children, the vastus lateralis muscle located over the anterior thigh is the preferred site for intramuscular injections. This site is chosen for its large muscle mass and reduced risk of injury to major nerves and blood vessels. Infants have less developed muscle structures, making the vastus lateralis a safer and more effective site for injections compared to other sites like the deltoid, ventrogluteal, or dorsogluteal. Using the correct injection site is essential to prevent complications and ensure the proper absorption of the medication.